A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make?

Choice A: “Monitor blood glucose levels every 4 hours.” This is the priority action for the nurse to recommend to the client because it will help them detect and prevent hyperglycemia or hypoglycemia, which can lead to serious complications such as diabetic ketoacidosis or cerebral edema.

Choice B: “Consume 15 grams of carbohydrates every 1 to 2 hours.” This is an important action for the nurse to recommend to the client, but not the priority. The client should consume carbohydrates to prevent hypoglycemia, especially if they have nausea, vomiting, or diarrhea, but this should be done after monitoring their blood glucose levels.

Choice C: “Drink 8 ounces of fluid every hour while awake.” This is a necessary action for the nurse to recommend to the client, but not the priority. The client should drink fluids to prevent dehydration and electrolyte imbalance, which can worsen hyperglycemia, but this should be done after monitoring their blood glucose levels.

Choice D: “Take the usual dosage of insulin.” This is a required action for the nurse to recommend to the client, but not the priority. The client should take their insulin as prescribed to control their blood glucose levels, but this should be done after monitoring their blood glucose levels and adjusting the dosage if needed.

Choice A: “You shouldn’t feel any pain since the local area is anaesthetized.” This is not a response that the nurse should make to the client who is scheduled for a colonoscopy. The nurse should not tell the client that they will not feel any pain, as this may create unrealistic expectations and increase anxiety if they do experience discomfort. The nurse should also not tell the client that the local area is anaesthetized, as this is not true. The client does not receive local anesthesia for a colonoscopy, but rather sedation and pain medication.

Choice B: “Don’t worry, you won’t remember anything about the procedure due to the effects of the medication.” This is not a response that the nurse should make to the client who is scheduled for a colonoscopy. The nurse should not tell the client not to worry, as this may sound dismissive and insensitive to their concerns. The nurse should also not tell the client that they will not remember anything about the procedure, as this is not true. The client may receive conscious sedation for a colonoscopy, which means that they are awake but drowsy and relaxed. They may have some memory loss of the procedure, but they are not completely unconscious.

Choice C: “Most clients report more discomfort from the preparation than from the procedure itself.” This is not a response that the nurse should make to the client who is scheduled for a colonoscopy. The nurse should not compare the client’s experience to other clients, as this may minimize their feelings and individual differences. The nurse should also not focus on the preparation, which involves drinking a large amount of liquid laxative to empty the colon, as this may increase anxiety and dread for the client. The nurse should instead focus on providing information and support for both the preparation and the procedure.

Choice D: “You may feel some cramping during the procedure.” This is a response that the nurse should make to the client who is scheduled for a colonoscopy, which is a diagnostic test that uses a flexible tube with a camera to examine the colon and rectum. The nurse should inform the client that they may feel some cramping during the procedure as the tube is inserted and moved through the colon. The nurse should also reassure the client that they will receive sedation and pain medication to make them comfortable and relaxed.